A 6-year-old female patient visited an outpatient clinic with syndactyly in bilateral hand and foot. On physical examination, all the web spaces in hand and foot were involved (Fig. 1). Skin contracture and ulnar deviation of in proximal, middle, distal interphalangeal (IP) joints and metacarpophalangeal (MCP) joint were noted. Also, flexion ontracture, active and passive limitation of extensors were noted in proximal, middle, distal IP joints, and MCP joints (Fig. 2). These features were related to characteristics of HI patient. The patient was unable to grasp objects with her hand despite prolonged physical therapy. To improve her hand function, surgical intervention was determined. The decision was made to perform surgery on the second web space of right hand. A dorsal rectangular flap and a volar triangular flap were designed (Fig. 3). After the division of second and third finger, a dorsal rectangular flap and a volar triangular flap flaps were interposed to recreate the second web. After interposition of flaps, the raw surface was covered with full thickness skin sized 4×2 cm harvested from the left inguinal crease (Fig. 4). Postoperatively, compressive dressing with gauze and an elastic bandage was maintained for 2 weeks. Interposed flaps healed well and full thickness skin grafts were taken perfectly. After 6 months, reconstructed web space was maintained without recurrence (Fig. 5). Six months follow up X-ray image showed significant improvement of ulnar drift. The ulnar deviation angle at MCP joint of second finger corrected from 60 to 25 degree (Fig. 6). In addition, functional improvements were evident by the patient being able to manipulate the joystick of her electric wheelchair and grasp paper money. However, patient underwent minor wound dehiscence in left inguinal donor site, which managed revision and moisturization (Fig. 7).

There is a lack of clinical outcome of syndactyly correction in HI patients. However, longer life expectancy are now achieved with the improvement of care for HI patients5. Since keratinocyte-fibroblast interaction is one of the key steps in wound healing8, dysregulation of epidermal differentiation in HI patients might have negative impact on wound healing. So we concerned of wound healing after surgery. However, functional and aesthetic aspects were improved after surgery. This might suggest that angular contracture of HI patients might be secondary to skin contracture instead of joint problems. So we suggest that adequate release of syndactyly and contracture is important in HI patient. So in HI patients, standard surgical options for syndactyly could be adjustable. In addition, we would like to recommend carefully design the flaps to minimize the raw surface for skin graft due to insufficient skin laxity for full thickness skin donor site. Additionally, one of important postoperative management is moisturizing of recipient and donor site. Moisturizing in HI patients might promote wound healing and contribute to skin contracture release and soften skin scale. Overland and Johnstone9 previously reported hand manifestations of HI patient treated with full thickness skin graft and had no complications. We expect that fullthickness skin graft can be safely performed on HI patient. In conclusion, we successfully managed syndactyly in an HI patient with full thickness skin grafts without any complication and saw improvement functionally and aesthetically.